HEAD AND NECK INFECTIONS









Bell palsy

Overview

  • Up to 30% of patients with Bell palsy fail to recover full facial function
  • Corticosteroids increase the probability of full recovery by 12 - 15%
  • Antivirals have no proven benefit, but a small one cannot be ruled out [1]
  • Cause of Bell palsy is unknown, but thought to be related to herpes virus infection [2]

Treatment (AAN 2012)

For patients with new-onset Bell palsy, the following treatments are recommended:
  • NOTE: "New-onset" is typically defined as within 72 hours of symptom onset
  • Corticosteroids - should be offered; no specific dosage is recommended; trials cited in the recommendation used prednisone-equivalent doses of 50 - 60 mg a day for 5 - 10 days. ($)
  • Antivirals - might be offered; no specific dosage is recommended; trials cited in the recommendation used one of the following:



Conjunctivitis (pink eye)

Overview

  • Up to 80% of acute conjunctivitis is viral
  • Bacterial conjunctivitis is typically a self-limited infection that resolves without treatment. Antibiotics may speed recovery time.
  • In general, most patients are prescribed antibiotic drops because there is no pathognomonic feature that distinguishes between bacterial and viral conjunctivitis
  • No clinical evidence suggests superiority of one antibiotic over another
  • Neisseria gonorrhoeae and Chlamydia trachomatis infections require systemic therapy [4,5]

Treatment


Aminoglycosides
Gentamicin (Garamycin®) ointment 1/2 inch 2 - 3 times a day for 1 week ($)
solution standard: 1 - 2 drops every 4 hours for 1 week | severe infection: 1 - 2 drops every hour ($)
Tobramycin (Tobrex®) ointment standard: 1/2 inch 3 times a day for 1 week | severe infection: 1/2 inch every 3 - 4 hours ($)
solution standard: 1 - 2 drops every 4 hours for 1 week | severe infection: 2 drops every hour ($)
Quinolones
Besifloxacin (Besivance®) suspension 1 drop 3 times a day for 7 days ($$$)
Ciprofloxacin (Ciloxan®) ointment 1/2 inch 3 times a day for 2 days, then 1/2 inch twice a day for 5 days ($$$)
solution 1 - 2 drops every 2 hours while awake for 2 days, then 1 - 2 drops every 4 hours while awake for 5 days ($)
Gatifloxacin (Zymaxid®) solution 1 drop every 2 hours while awake, up to 8 times on Day 1, then 1 drop 2 - 4 times a day on Days 2 - 7 ($$)
Levofloxacin (Quixin®) solution 1 - 2 drops every 2 hours while awake, up to 8 times on Days 1 and 2, then 1 - 2 drops 4 times a day on Days 3 - 7 ($)
Moxifloxacin (Vigamox®) solution 1 drop 3 times a day for 7 days ($)
Moxifloxacin (Moxeza®) solution 1 drop 2 times a day for 7 days ($$$$)
Ofloxacin (Floxin®) solution 1 - 2 drops every 2 - 4 hours while awake on Days 1 and 2, then 1 - 2 drops 4 times a day on Days 3 - 7 ($)
Macrolides
Azithromycin (Azasite®) solution 1 drop twice daily on Days 1 and 2, then 1 drop daily on Days 3 - 7 ($$$)
Erythromycin ointment 1 cm up to 6 times a day for 1 week ($)
Sulfa
Sulfacetamide (Bleph-10®) solution 1 - 2 drops every 2 -3 hours initially, then taper. Treat for 7 days. ($)
Other
Polymyxin B + trimethoprim (Polytrim®) solution 1 drop every 3 hours (max of 6/day) for 7 - 10 days ($)







Otitis media

Overview

  • Amoxicillin-clavulanate preparations with a 14:1 ratio of amoxicillin-clavulanate are less likely to cause diarrhea than preparations with a lower ratio
  • Cefdinir, cefuroxime, cefpodoxime, and ceftriaxone are highly unlikely to cross-react in penicillin-allergic patients because they differ significantly in chemical structure [7]
  • Ear tubes are generally recommended in children with otitis media lasting longer than 3 months
  • Ear tubes are not recommended in children with recurrent otitis media who do not have a chronic middle ear effusion [8]

Treatment

Pediatric (AAP recommendations) Other
  • Clindamycin - 30–40 mg/kg/day given in 3 divided doses for 5 - 10 days ($$-$$$) [7]
Length of therapy
  • Age < 2 years: 10 days of therapy
  • Age 2 - 5 years: 7 days of therapy
  • Age ≥ 6 years: 5 - 7 days of therapy

Studies

Oral Steroids vs Placebo for OM with Effusion, Lancet (2018) [PubMed abstract]
  • Design: Randomized, placebo-controlled trial (N=389 | length = 5 weeks) in children aged 2-8 years with otitis media with effusion for at least 3 months and confirmed bilateral hearing loss
  • Treatment: Prednisolone 20 - 30 mg once daily for 7 days vs Placebo
  • Primary outcome: audiometry-confirmed acceptable hearing at 5 weeks
  • Results:
    • Primary outcome: Prednisolone - 40%, Placebo - 33% (p=0.16)
  • Findings: Otitis media with effusion in children with documented hearing loss and attributable symptoms for at least 3 months has a high rate of spontaneous resolution. A short course of oral prednisolone is not an effective treatment for most children aged 2 – 8 years with persistent otitis media with effusion, but is well tolerated. One in 14 children might achieve improved hearing but not quality of life. Discussions about watchful waiting and other interventions will be supported by this evidence.
Five Days vs Ten Days of Augmentin for Acute OM, NEJM (2016) [PubMed abstract]
  • Design: Randomized, placebo-controlled trial (N=520 | length = mean of 4.2 months) in children 6 to 23 months of age with acute otitis media
  • Treatment: Augmentin 90 mg/6.4 mg/kg/day for 5 days vs 10 days
  • Primary outcome: clinical failure
  • Results:
    • Primary outcome: Five days - 34%, Ten days - 16% (diff 17%, 95%CI [9 - 25])
  • Findings: Among children 6 to 23 months of age with acute otitis media, reduced-duration antimicrobial treatment resulted in less favorable outcomes than standard-duration treatment; in addition, neither the rate of adverse events nor the rate of emergence of antimicrobial resistance was lower with the shorter regimen



Otitis media with perforation or ear tubes (suppurative)

Overview

  • Ear drops are preferred over oral medications in otitis media with perforation and otitis media with ear tubes
  • Ototoxicity from aminoglycosides (neomycin, gentamicin, tobramycin) is controversial. There have been case reports of ototoxicity, but no definitive link has been established.
  • Cortisporin otic suspension is preferred over Cortisporin otic solution because it has a higher pH and may be less irritating
  • Ear tubes are generally recommended in children with otitis media lasting longer than 3 months
  • Ear tubes are not recommended in children with recurrent otitis media who do not have a chronic middle ear effusion
  • Ear plugs are not recommended for swimming, etc. in children with ear tubes [8,9]

Treatment

First-line (FDA-approved)
  • Ofloxacin (Floxin otic®)
    • Ear tubes - Five drops instilled into the affected ear twice daily for ten days. Warm bottle first by holding in hand. The patient should lie with the affected ear upward, and then the drops should be instilled. The tragus should be pumped 4 times by pushing inward to facilitate penetration of the drops into the middle ear. This position should be maintained for five minutes.
    • Perforated TM - Ten drops instilled into the affected ear twice daily for fourteen days. Warm bottle first by holding in hand. The patient should lie with the affected ear upward, and then the drops should be instilled. The tragus should be pumped 4 times by pushing inward to facilitate penetration into the middle ear. This position should be maintained for five minutes. ($)
  • Ciprofloxacin and fluocinolone (Otovel®)
    • Ear tubes - Instill the contents of one single-dose vial (0.25 ml) into the affected ear canal twice daily (approximately every 12 hours) for 7 days. Warm the solution by holding the vial in the hand for 1 to 2 minutes. Lie with the affected ear upward. Pump the tragus four times. Maintain position for 1 minute. ($$$$)
  • Ciprofloxacin and dexamethasone (Ciprodex®)
    • Ear tubes - Four drops instilled into the affected ear twice daily for seven days. Warm bottle first by holding in hand. The tragus should be pumped 5 times by pushing inward to facilitate penetration of the drops into the middle ear. This position should be maintained for 60 seconds. ($$$$)
Other (not FDA-approved)
  • Cortisporin-TC® (colistin, neomycin, thonzonium, hydrocortisone) - otic suspension; 4 - 5 drops in affected ear 3 - 4 times a day. The patient should lie with the affected ear upward and then the drops should be instilled. This position should be maintained for 5 minutes to facilitate penetration of the drops into the ear canal. ($$$$)
  • Ophthalmic drops - gentamicin, tobramycin, and ciprofloxacin ophthalmic drops have been used. See conjunctivitis above. [9]



Otitis externa (swimmer's ear)

Treatment

  • Acetic acid solution (Vosol®) - insert a wick of cotton saturated with acetic acid into the ear canal. Keep the wick in for at least 24 hours and keep it moist by adding 3 to 5 drops of Acetic Acid every 4 to 6 hours. The wick may be removed after 24 hours. Continue to instill 3 - 5 drops of acetic acid 3 or 4 times daily thereafter, for as long as indicated. ($)
  • Acetic acid and hydrocortisone solution (Vosol HC®, Acetasol HC®) - insert a wick of cotton saturated with acetic acid into the ear canal. Keep the wick in for at least 24 hours and keep it moist by adding 3 to 5 drops of acetic acid every 4 to 6 hours. The wick may be removed after 24 hours. Continue to instill 3 - 5 drops of acetic acid 3 or 4 times daily thereafter, for as long as indicated ($$)
  • Ciprofloxacin and dexamethasone (Ciprodex®) - Four drops instilled into the affected ear twice daily for seven days. Warm bottle by holding in hand before use. The patient should lie with the affected ear upward. This position should be maintained for 60 seconds. ($$$$)
  • Ciprofloxacin and hydrocortisone (Cipro HC®) - For children (age 1 year and older) and adults, 3 drops of the suspension should be instilled into the affected ear twice daily for seven days. Warm bottle by holding in hand before use. The patient should lie with the affected ear upward and then the drops should be instilled. This position should be maintained for 30-60 seconds to facilitate penetration of the drops into the ear. ($$$$)
  • Cortisporin Otic® (neomycin, polymyxin b, hydrocortisone) - otic solution; 3 - 4 drops in affected ear 3 - 4 times a day. The patient should lie with the affected ear upward and then the drops should be instilled. This position should be maintained for 5 minutes to facilitate penetration of the drops into the ear canal. Do not use for more than 10 days. ($)
  • Cortisporin-TC® (colistin, neomycin, thonzonium, hydrocortisone) - otic suspension; 4 - 5 drops in affected ear 3 - 4 times a day. The patient should lie with the affected ear upward and then the drops should be instilled. This position should be maintained for 5 minutes to facilitate penetration of the drops into the ear canal. Do not use for more than 10 days. ($$$$)
  • Finafloxacin otic suspension (Xtoro®) - For children (age 1 year and older) and adults, instill four drops into the affected ear(s) twice daily for seven days. Warm bottle by holding in hand before use. Shake bottle well. Lie with the affected ear upward, instill the drops, and maintain the position for 60 seconds to facilitate penetration of the drops into the ear canal. ($$$$)
  • Ofloxacin (Floxin otic®)
    • Pediatric (from 6 months to 13 years old) - Five drops instilled into the affected ear once daily for seven days. Warm bottle by holding in hand before use. The patient should lie with the affected ear upward, and then the drops should be instilled. This position should be maintained for five minutes. ($)
    • Patients ≥ 13 years - Ten drops instilled into the affected ear once daily for seven days. Warm bottle by holding in hand before use. The patient should lie with the affected ear upward, and then the drops should be instilled. This position should be maintained for five minutes. ($)



Pulpitis (Toothache)

Treatment

  • Antibiotics are widely prescribed for toothache, or "pulpitis" which is the medical term for the condition
  • Penicillin, amoxicillin, amoxicillin-clavulanate, and clindamycin are the antibiotics that are typically used
  • No large, randomized controlled trials have evaluated the use of antibiotics in pulpitis [13]
  • One small trial involving 40 patients found no benefit of penicillin when compared to placebo [PubMed abstract]
  • No good evidence supports the use of antibiotics in uncomplicated pulpitis









Thrush (oral candidiasis)

Overview

  • Thrush is caused by Candida sp, most commonly C albicans
  • Risk factors include advanced age, dentures, diabetes, immunocompromised state (e.g. HIV/AIDS, cancer, chemotherapy), steroid inhalers, antibiotic use, Cushing's syndrome, salivary gland dysfunction (e.g. Sjögren's syndrome, radiation to the head and neck) nutritional deficiencies, high carbohydrate diet, and smoking
  • Other conditions that can present as white patches in the mouth include lichen planus, squamous cell carcinoma, lichenoid reaction, and leukoplakia
  • Thrush lesion can typically be scraped off to expose underlying erythema
  • Patients with thrush should practice good oral hygiene including regular brushing of the teeth, gums, and mouth, cleaning and soaking dentures, and removing dentures at night
  • In rare cases, systemic therapy may be necessary [20]

Treatment

Pediatric
  • Infants
    • Nystatin suspension 100,000 units/ml - 2 ml (200,000 units) four times a day. Place 1 ml in each side of mouth and avoid feeding for 5 - 10 minutes. Continue treatment for at least 48 hours after lesions have disappeared. ($)
  • Children
    • Nystatin suspension 100,000 units/ml - 4 - 6 ml (400,000 - 600,000 units) four times a day. Solution should be swished and swallowed. Retain in mouth as long as possible. Continue treatment for at least 48 hours after lesions have disappeared. ($)
Adults
  • Clotrimazole troche (Mycelex®)
    • Active infection - place one troche (10 mg) in mouth and allow to dissolve five times a day for 14 days ($-$$)
    • Prophylaxis (e.g. chemo, radiation) - place one troche (10 mg) in mouth and allow to dissolve three times a day for duration of therapy ($+)
  • Miconazole (Oravig®) - apply one buccal tablet (50 mg) to the upper gum once daily for 14 days ($$$$)
  • Nystatin suspension 100,000 units/ml - 4 - 6 ml (400,000 - 600,000 units) four times a day. Solution should be swished and swallowed. Retain in mouth as long as possible. Continue treatment for at least 48 hours after lesions have disappeared. ($)



Pricing legend
  • $ = 0 - $50
  • $$ = $51 - $100
  • $$$ = $101 - $150
  • $$$$ = > $151
  • Pricing based on one month of therapy at standard dosing in an adult
  • Pricing based on information from GoodRX.com®
  • Pricing may vary by region and availability